The ratio of ApoB to LDL-C increased as LDL-C decreased, consistent with small, dense particle prominence at lower LDL-C levels. ApoB measurement may identify a substantial proportion of pts with lower LDL-C who have persistently elevated atherogenic particle numbers.
Have you seen this ApoB/LDL-C ratio increase in your patients who have achieved an LDL in the 20s.
Does it concern you that at low LDL levels the remaining LDL particles may be smaller?
Do you care about the ratio if your patients are able to get their ApoB below 60?
I havent read the paper in depth but I suspect it relates to smaller dense LDL particles being less effectively cleared and therefore as a relative % would increase (as they are the only ones left). In my view smaller dense LDL particles are a concern but are usually more a function of insulin resistance. So yes I am worried by them but the solution I find usually lies in addressing the IR. Hope that helps.
Thanks for your answer. It's not easy to convince your GP to take statins when you're young and healthy, but have an apoB level of 93 mg/dl (average LDL-C level).
Depending on the level of risk, family history and also the desire of the patient to de risk. Will be interesting to see the results of PRECAD but the guidelines are already quite clear. Assessment should include a discussion of lifetime cardiovascular risk and also "Treatment recommendations are never ‘imperative’ for high risk patients, nor are interventions ever ‘prohibited’ for patients at low-to-moderate risk. " ESC Prevention Guidelines 2021
Hi there, I just got my biomarkers tested and a few of my numbers concerned me. I am a healthy 28 year old female with good cholesterol, and my ApoB is 77mg/dL. However my HDL Large particles are below range at 6,192 nmol/L, my LDL Medium Particles are above range at 344 nmol/L, and my LDL small Particle size is at 236 nmol/L. I also have an LDL total particle number that is 1,662 nmol/L. Can you have a healthy range of ApoB and a surplus of LDL-p? Is that better than high ApoB low LDL-p? I’m a bit puzzled!
I have asked my primary care physician to do my ApoB at my last 2 annual exams and he refuses. I am a 61 year old, female, overweight by 35 lbs with visceral fat, med controlled hypertensive on statins for hypercholesterolemia , A1C 5.7. My 56 yr old brother just had a major MI. I am aggressively implementing dietary/exercise lifestyle changes. So frustrating to be dismissed by my GP.
You can approximate with your Non-HDL. The main reason GPs are reluctant to do it is usually because they are not familiar with how to interpret it. There are ways to get it done directly with home testing kits which you would have to research online.
I an Asian that has a strong family history of atherosclerotic heart disease. My blood pressure is well controlled (<120/75) and my LDL is 32 on Crestor and Zetia. Do you see any obvious benefit to measuring Apo B.
I can’t give individual patient advice unfortunately but the entire piece is about why LDL or even non HDL can be insufficient as a marker of risk, even on treatment. It’s usually fine. But often not.
I guess my larger question was if you still test for Apo B in your patients who have excellent lipid numbers on maximum statin doses or from PCSK 9 inhibitors.
I suppose it still provides some useful information even if you have run out of the usual therapies.
Do you have patients who are not convinced enough to alter their lifestyle by a standard lipid panel, but are convinced enough to do so by a high apoB number?
Thanks. I request it on all of my patients - I do not always get a result as often labs are done in primary care setting prior to review and frequently not done. It's not about convincing patients, it's about accuracy. Sometimes we need do not need to treat and sometimes we are under the illusion that we have gotten to target.
https://www.jacc.org/doi/epdf/10.1016/S0735-1097%2823%2902266-0 March 2023 JACC
The ratio of ApoB to LDL-C increased as LDL-C decreased, consistent with small, dense particle prominence at lower LDL-C levels. ApoB measurement may identify a substantial proportion of pts with lower LDL-C who have persistently elevated atherogenic particle numbers.
Have you seen this ApoB/LDL-C ratio increase in your patients who have achieved an LDL in the 20s.
Does it concern you that at low LDL levels the remaining LDL particles may be smaller?
Do you care about the ratio if your patients are able to get their ApoB below 60?
Thanks. I think your substack letter is great!
I havent read the paper in depth but I suspect it relates to smaller dense LDL particles being less effectively cleared and therefore as a relative % would increase (as they are the only ones left). In my view smaller dense LDL particles are a concern but are usually more a function of insulin resistance. So yes I am worried by them but the solution I find usually lies in addressing the IR. Hope that helps.
Hey Doc thanks for your article. Top ressources
If I understand well, we should be lowering our ApoB level below 60 mg/dl.
Is nutrition modification may be sufficient to reach these goal ( with reduction of satured fats, more of fiber...) or medication is required?
At what age should we start taking statins if the ApoB level is in the 50 percent range?
Thank's
Nutrition will be helpful but is rarely sufficient if levels very high. When you start lowering in my view - the earlier the better.
Thanks for your answer. It's not easy to convince your GP to take statins when you're young and healthy, but have an apoB level of 93 mg/dl (average LDL-C level).
It’s hard as the guidelines overly emphasise 10 yr risk reduction rather than lifetime risk reduction.
Are you starting to treat young patients in the 20s and 30s with statins with LDLs greater than 70 or 100?
I see that there is a PRECAD that was announced recently to answer these questions
Depending on the level of risk, family history and also the desire of the patient to de risk. Will be interesting to see the results of PRECAD but the guidelines are already quite clear. Assessment should include a discussion of lifetime cardiovascular risk and also "Treatment recommendations are never ‘imperative’ for high risk patients, nor are interventions ever ‘prohibited’ for patients at low-to-moderate risk. " ESC Prevention Guidelines 2021
Exactly
Another great article Doc. Do statins reduce the ApoB if VLDL is procured primarily in the Liver ?
Yes
Thanks got another informative article. If APOB is high, can anything be done about it to reduce risk?
Yes. Lots. Can be completely normalised with lipid lowering therapy.
If it’s not routine to check - are bought tests (on line) accurate enough to check for the APOB levels? And if so which ?🙏
Just because it isn’t routine doesn’t mean it can’t be done. Would aim to do in an accredited lab where most of your blood tests are processed
It's not make in routine. But, at least in France, I was able to do it with no additional cost
Hi there, I just got my biomarkers tested and a few of my numbers concerned me. I am a healthy 28 year old female with good cholesterol, and my ApoB is 77mg/dL. However my HDL Large particles are below range at 6,192 nmol/L, my LDL Medium Particles are above range at 344 nmol/L, and my LDL small Particle size is at 236 nmol/L. I also have an LDL total particle number that is 1,662 nmol/L. Can you have a healthy range of ApoB and a surplus of LDL-p? Is that better than high ApoB low LDL-p? I’m a bit puzzled!
In general ApoB is a better marker
Thank you!
I have asked my primary care physician to do my ApoB at my last 2 annual exams and he refuses. I am a 61 year old, female, overweight by 35 lbs with visceral fat, med controlled hypertensive on statins for hypercholesterolemia , A1C 5.7. My 56 yr old brother just had a major MI. I am aggressively implementing dietary/exercise lifestyle changes. So frustrating to be dismissed by my GP.
You can approximate with your Non-HDL. The main reason GPs are reluctant to do it is usually because they are not familiar with how to interpret it. There are ways to get it done directly with home testing kits which you would have to research online.
Thank you, and for your articles. I find them very informative. I will do this and hopefully be able to interpret myself.
I an Asian that has a strong family history of atherosclerotic heart disease. My blood pressure is well controlled (<120/75) and my LDL is 32 on Crestor and Zetia. Do you see any obvious benefit to measuring Apo B.
I can’t give individual patient advice unfortunately but the entire piece is about why LDL or even non HDL can be insufficient as a marker of risk, even on treatment. It’s usually fine. But often not.
Totally understand.
I guess my larger question was if you still test for Apo B in your patients who have excellent lipid numbers on maximum statin doses or from PCSK 9 inhibitors.
I suppose it still provides some useful information even if you have run out of the usual therapies.
I generally do when possible.
I should add that my non HDL is 47
Excellent article (again), thank you! I'm genuinely curious:
Do you order an apoB test for all your patients?
Do you have patients who are not convinced enough to alter their lifestyle by a standard lipid panel, but are convinced enough to do so by a high apoB number?
Thanks. I request it on all of my patients - I do not always get a result as often labs are done in primary care setting prior to review and frequently not done. It's not about convincing patients, it's about accuracy. Sometimes we need do not need to treat and sometimes we are under the illusion that we have gotten to target.
There are papers that talk about using the ratio of LDL-C/ Apo B as a proxy for particle size.
Do you pay attention to this ratio or do you concentrate on achieving the lowest Apo B. Do you have Apo B goal numbers for various risk classes?
I have found your article and answers very informative! Thank you!
I tend to view particle size as a proxy marker of insulin resistance which you can measure directly which I prefer. Re APOB, here are my general thoughts: https://paddybarrett.substack.com/p/why-you-need-to-measure-apob-to-assess
Thanks very much!